Optimizing Perioperative Red Blood Cell Utilization and Wastage in Pediatric Craniofacial Surgery.

Utilization, wastage, and adverse consequences of assigning one full red blood cell (RBC) unit were investigated for children undergoing craniosynostosis surgery. The authors hypothesized that significant RBC wastage in the perioperative period exists for pediatric craniofacial surgery. The authors sought to determine what factors could guide patient-specific blood product preparation by evaluating utilization and wastage of RBCs in pediatric patients undergoing surgical correction of craniosynostosis. Eighty-five children with craniosynostosis undergoing surgical correction at our institution between July 2013 and June 2015 were identified. Fifty-three patients received RBC transfusion in the perioperative period, while 32 patients were not transfused. Primary outcome measures were intraoperative, postoperative, and total percent of RBC wastage. Secondary analysis compared the impact of patient weight and procedure type on perioperative RBC wastage. Of the 53 patients who received perioperative RBC transfusion, 35 patients received a volume of blood less than the full volume of the RBC unit while 18 patients received the full volume of blood. There was no significant relationship between perioperative RBC wastage, the type of craniofacial procedure performed, or the duration of surgical time. Children who received a perioperative transfusion and had RBC wastage weighed significantly less than those who received a full volume. These findings suggest that for craniofacial surgical patients weighing less than 10 kg, a protocol that splits cross-matched RBC units can decrease perioperative RBC wastage and blood donor exposure. A future prospective study will determine the success of this intervention as well as the potential to decrease exposure to multiple blood donors.

Delayed Emergence in Pediatric Patients with Neurologic Disease Presenting for Ambulatory Surgery.

OBJECTIVES: Management of pediatric patients with neurological diagnoses can be challenging for anesthesiologists. We sought to determine whether preexisting neurologic disease could serve as an intrinsic risk factor for prolonged emergence. METHODS: Following institutional review board approval, we conducted a database search from 2012 to 2015. Included were patients aged 0 to 18 years undergoing ambulatory procedures, and carrying neurological diagnoses that profoundly affected their development. Patients were excluded if they received a total intravenous anesthetic, were not managed with an endotracheal tube, or were extubated deep. A healthy case-control group also was obtained for comparison. The primary outcome was emergence from anesthesia: time from anesthetic cessation to extubation. Our secondary outcome was time from extubation to discharge. Descriptive statistics were calculated for demographic data, outcomes were analyzed for differences using the Student t test, and regression analysis was performed. RESULTS: Data from 69 patients and 169 controls met criteria. There were no differences between study and control groups for age, sex, procedural length, or intraoperative temperatures. The study group had higher American Society of Anesthesiologists scores (2.4 vs 1.4). The primary outcome of time to emergence was longer in the study group (15.2 vs 11.0 min), and time to discharge also was prolonged (101.0 vs 86.1 min). Regression analysis on most differing variables did not yield a correlation to primary/secondary outcomes, but neurologic disease did correlate to both. CONCLUSIONS: In this case-controlled retrospective study, there was a prolongation of anesthetic emergence and hospital discharge times for pediatric patients with severe neurologic disease, mostly independent of external factors.

Tailoring the Blood Ordering Process for Cardiac Surgical Cases Using an Institution-Specific Version of the Maximum Surgical Blood Order Schedule.

BACKGROUND: Excess ordering of blood products for surgical cases is expensive and wasteful. Evidence has shown that institution-specific versions of the Maximum Surgical Blood Order Schedule (MSBOS) lead to better ordering practices. Most MSBOSs recommend a crossmatch for a minimum of 2 units of packed red blood cells (PRBCs) for cardiac surgical cases; however, studies have shown that >50% of these patients receive no transfusions. Our aim was to create a blood order algorithm for cardiac surgical cases that would decrease unnecessary crossmatching. METHODS: Retrospective data was collected for 264 patients from January 2011 through April 2012. The crossmatch-to-transfusion ratio (C:tx), transfusion probability (%T), and transfusion index (TI) were calculated for each type of procedure. RESULTS: All 264 patients were crossmatched and 98 patients were transfused, resulting in an overall transfusion probability (%T) of 37.12% (95% confidence interval 31.52-43.09). A total of 1175 units of blood were crossmatched, but only 370 units of blood were transfused, resulting in a C:tx of 3.17 (95% confidence interval 2.61-4.03). The average number of units transfused per procedure (transfusion index) was 1.40. C:tx was highest and TI was lowest for CABG, where approximately 11 units of blood were ordered for every 1 unit transfused (C:tx =11.70 ± 3.04), and the TI was 0.32. CONCLUSIONS: Using the gold standard C:tx of >2:1 as an indicator of inappropriate blood utilization, our analysis confirmed that excessive crossmatching occurred for several procedures. Now a subset of cardiac surgical cases only requires a type and screen order prior to surgery.

Anesthetic Management of the Parturient for Lumbar Disc Surgery in the Prone Position.

BACKGROUND: While back pain is common in pregnancy, urgent surgical intervention is rarely required. CASE REPORT: A parturient in the third trimester presented with foot drop and sensory deficits. Surgical intervention was deemed necessary and was performed in the prone position to facilitate exposure. A multidisciplinary approach was vital to the management plan. CONCLUSION: For any pregnant patient undergoing nonobstetric surgery, the care provided should be individualized and thoughtful, keeping in mind both the mother and fetus.

Serotonin syndrome.

BACKGROUND: Serotonin syndrome is a potentially life-threatening syndrome that is precipitated by the use of serotonergic drugs and overactivation of both the peripheral and central postsynaptic 5HT-1A and, most notably, 5HT-2A receptors. This syndrome consists of a combination of mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity. Serotonin syndrome can occur via the therapeutic use of serotonergic drugs alone, an intentional overdose of serotonergic drugs, or classically, as a result of a complex drug interaction between two serotonergic drugs that work by different mechanisms. A multitude of drug combinations can result in serotonin syndrome. METHODS: This review describes the presentation and management of serotonin syndrome and discusses the drugs and interactions that can precipitate this syndrome with the goal of making physicians more alert and aware of this potentially fatal yet preventable syndrome. CONCLUSION: Many commonly used medications have proven to be the culprits of serotonin syndrome. Proper education and awareness about serotonin syndrome will improve the accuracy of diagnosis and promote the institution of the appropriate treatment that may prevent significant morbidity and mortality.

QT interval abnormalities: risk factors and perioperative management in long QT syndromes and Torsades de Pointes.

Electrophysiological abnormalities of the QT interval of the standard electrocardiogram are not uncommon. Congenital long QT syndrome is due to mutations of several possible genes (genotype) that result in prolongation of the corrected QT interval (phenotype). Abnormalities of the QT interval can be acquired and are often drug-induced. Torsades de Pointes (TP) is an arrhythmia that is a result of aberrant repolarization/QT abnormalities. If not recognized and corrected quickly, QT interval abnormalities may precipitate potentially fatal ventricular dysrhythmias. The main mechanism responsible for the development of QT prolongation is blockade of the rapid component of the delayed rectifier potassium current (I kr), encoded for by the human-ether-a-go-go-related gene (hERG). The objectives of this review were (1) to describe the electrical pathophysiology of QT interval abnormalities, (2) to differentiate congenital from acquired QT interval abnormalities, (3) to describe the currently known risk factors for QT interval abnormalities, (4) to identify current drug-induced causes of acquired QT interval abnormalities, and (5) to recommend immediate and effective management strategies to prevent unanticipated dysrhythmias and deaths from QT abnormalities in the perioperative period.